=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467960385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAKE HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2018
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15085 SE 73RD AVE
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-504-6979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15085 SE 73RD AVE
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYLE BLAKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-504-6979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------